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1.  Development of the Diabetes Indicators and Data Sources Internet Tool (DIDIT) 
Preventing Chronic Disease  2005;3(1):A20.
Developing a Web-based tool that involves the input, buy-in, and collaboration of multiple stakeholders and contractors is a complex process. Several elements facilitated the development of the Web-based Diabetes Indicators and Data Sources Internet Tool (DIDIT). The DIDIT is designed to enhance the ability of staff within the state-based Diabetes Prevention and Control Programs (DPCPs) and the Centers for Disease Control and Prevention (CDC) to perform diabetes surveillance. It contains information on 38 diabetes indicators (measures of health or factors associated with health) and 12 national- and state-level data sources. Developing the DIDIT required one contractor to conduct research on content for diabetes indicators and data sources and another contractor to develop the Web-based application to house and manage the information. During 3 years, a work group composed of representatives from the DPCPs and the Division of Diabetes Translation (DDT) at the CDC guided the development process by 1) gathering information on and communicating the needs of users and their vision for the DIDIT, 2) reviewing and approving content, and 3) providing input into the design and system functions. Strong leadership and vision of the project lead, clear communication and collaboration among all team members, and a commitment from the management of the DDT were essential elements in developing and implementing the DIDIT. Expertise in diabetes surveillance and software development, enthusiasm, and dedication were also instrumental in developing the DIDIT.
PMCID: PMC1500969  PMID: 16356373
2.  The Scope of Cell Phones in Diabetes Management in Developing Country Health Care Settings 
Diabetes has emerged as a major public health concern in developing nations. Health systems in most developing countries are yet to integrate effective prevention and control programs for diabetes into routine health care services. Given the inadequate human resources and underfunctioning health systems, we need novel and innovative approaches to combat diabetes in developing-country settings. In this regard, the tremendous advances in telecommunication technology, particularly cell phones, can be harnessed to improve diabetes care. Cell phones could serve as a tool for collecting information on surveillance, service delivery, evidence-based care, management, and supply systems pertaining to diabetes from primary care settings in addition to providing health messages as part of diabetes education. As a screening/diagnostic tool for diabetes, cell phones can aid the health workers in undertaking screening and diagnostic and follow-up care for diabetes in the community. Cell phones are also capable of acting as a vehicle for continuing medical education; a decision support system for evidence-based management; and a tool for patient education, self-management, and compliance. However, for widespread use, we need robust evaluations of cell phone applications in existing practices and appropriate interventions in diabetes.
PMCID: PMC3192644  PMID: 21722593
cell phones; decision support system; diabetes; mHealth; wireless
3.  Using the Essential Public Health Services as strategic leverage to strengthen the public health response to diabetes. 
Public Health Reports  2004;119(3):311-321.
If current trends continue, health systems will soon be overwhelmed by type 2 diabetes mellitus. Successful population-based diabetes prevention and control efforts require a sound and continually improving infrastructure. In states and U.S. territories, the Diabetes Prevention and Control Programs supported by the U.S. Centers for Disease Control and Prevention's Division of Diabetes Translation serve as a fulcrum for building and refining the infrastructure that links diverse and dynamic partners dedicated to increasing the years and quality of life and achieving health equity among people with and at risk for diabetes. The National Public Health Performance Standards offer a conceptual framework that articulates the requisite infrastructure and services provided by an interconnected network of intersectoral partners to strengthen the public health response to diabetes. These standards associated with the Essential Public Health Services are valuable tools to assess the status of the performance of the health system's infrastructure to guide improvement. The process of engaging system partners in a system-wide assessment informs and leverages cross-sectoral assets to improve health outcomes for citizens in communities shouldering the growing burden of diabetes.
PMCID: PMC1497627  PMID: 15158110
4.  The National Diabetes Education Program Evaluation Framework: How to Design an Evaluation of a Multifaceted Public Health Education Program 
Preventing Chronic Disease  2008;5(4):A134.
The National Diabetes Education Program, cosponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, employs mass media communications, public-private partnerships, and dissemination of information and education tools to address the diabetes epidemic in the United States. The program's goal is to help reduce the morbidity and mortality from diabetes and its complications by improving the treatment and outcomes for people with diabetes, promoting early diagnosis, and preventing onset of diabetes. Evaluation is an integral component of the National Diabetes Education Program's planning and implementation process. The program's evaluation is based on the Centers for Disease Control and Prevention's Framework for Program Evaluation in Public Health, which has guided program planners and evaluators in developing measurable short-term, midterm, and long-term outcomes. We describe how the National Diabetes Education Program has applied the evaluation framework, demonstrating how multifaceted health communications programs can design program evaluations to answer key questions about program processes and outcomes.
PMCID: PMC2578767  PMID: 18793522
5.  Using Secure Web Services to Visualize Poison Center Data for Nationwide Biosurveillance: A Case Study 
Online Journal of Public Health Informatics  2010;2(1):ojphi.v2i1.2920.
Real-time surveillance systems are valuable for timely response to public health emergencies. It has been challenging to leverage existing surveillance systems in state and local communities, and, using a centralized architecture, add new data sources and analytical capacity. Because this centralized model has proven to be difficult to maintain and enhance, the US Centers for Disease Control and Prevention (CDC) has been examining the ability to use a federated model based on secure web services architecture, with data stewardship remaining with the data provider.
As a case study for this approach, the American Association of Poison Control Centers and the CDC extended an existing data warehouse via a secure web service, and shared aggregate clinical effects and case counts data by geographic region and time period. To visualize these data, CDC developed a web browser-based interface, Quicksilver, which leveraged the Google Maps API and Flot, a javascript plotting library.
Two iterations of the NPDS web service were completed in 12 weeks. The visualization client, Quicksilver, was developed in four months.
This implementation of web services combined with a visualization client represents incremental positive progress in transitioning national data sources like BioSense and NPDS to a federated data exchange model.
Quicksilver effectively demonstrates how the use of secure web services in conjunction with a lightweight, rapidly deployed visualization client can easily integrate isolated data sources for biosurveillance.
PMCID: PMC3615758  PMID: 23569581
public health; surveillance; architecture; web services; SOA
6.  Measuring Health Behaviors in Populations 
Preventing Chronic Disease  2010;7(4):A75.
Health behaviors are a leading cause of illness and death in the United States. Efforts to improve public health require information on the prevalence of health behaviors in populations — not only to target programs to areas of most need but also to evaluate the effectiveness of intervention efforts. Telephone surveys, such as the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, are a good way to assess health behaviors in populations. These data provide estimates at the national and state level but often require multiple years of data to provide reliable estimates at the local level. With changes in telephone use (eg, rapid decline in the ownership of landlines), innovative methods to collect data on health behaviors, such as in health care settings or through Internet-based surveys, need to be developed.
PMCID: PMC2901573  PMID: 20550833
7.  Syndromic Surveillance Based on Emergency Visits: A Reactive Tool for Unusual Events Detection 
To show with examples that syndromic surveillance system can be a reactive tool for public health surveillance.
The late health events such as the heat wave of 2003 showed the need to make public health surveillance evolve in France. Thus, the French Institute for Public Health Surveillance has developed syndromic surveillance systems based on several information sources such as emergency departments (1). In Reunion Island, the chikungunya outbreak of 2005–2006, then the influenza pandemic of 2009 contributed to the implementation and the development of this surveillance system (2–3). In the past years, this tool allowed to follow and measure the impact of seasonal epidemics. Nevertheless, its usefulness for the detection of minor unusual events had yet to be demonstrated.
In Reunion Island, the syndromic surveillance system is based on the activity of six emergency departments. Two types of indicators are constructed from collected data: - Qualitative indicators for the alert (every visit whose diagnostic relates to a notifiable disease or potential epidemic disease);- Quantitative indicators for the epidemic/cluster detection (number of visits based on syndromic grouping).
Daily and weekly analyses are carried out. A decision algorithm allows to validate the signal and to organize an epidemiological investigation if necessary.
Each year, about 150 000 visits are registered in the six emergency departments that is 415 consultations per day on average. Several unusual health events on small-scale were detected early.
In August 2011, the surveillance system allowed to detect the first autochthonous cases of measles, a few days before this notifiable disease was reported to health authorities (Figure 1). In January 2012, the data of emergency departments allowed to validate the signal of viral meningitis as well as to detect a cluster in the West of the island and to follow its trend. In June 2012, a family foodborne illness was detected from a spatio-temporal cluster for abdominal pain by the surveillance system and was confirmed by epidemiological investigation (Figure 2).
Despite the improvement of exchanges with health practitioners and the development of specific surveillance systems, health surveillance remains fragile for the detection of clusters or unusual health events on small scale. The syndromic surveillance system based on emergency visits has proved to be relevant for the identification of signals leading to health alerts and requiring immediate control measures. In the future, it will be necessary to develop these systems (private practitioners, sentinel schools) in order to have several indicators depending on the degree of severity.
PMCID: PMC3692799
Syndromic surveillance; Unusual event detection; Reunion Island
8.  National Environmental Public Health Tracking Program: Bridging the Information Gap 
Environmental Health Perspectives  2004;112(14):1409-1413.
In January 2001 the Pew Environmental Health Commission called for the creation of a coordinated public health system to prevent disease in the United States by tracking and combating environmental health threats. In response, the Centers for Disease Control and Prevention initiated the Environmental Public Health Tracking (EPHT) Program to integrate three distinct components of hazard monitoring and exposure and health effects surveillance into a cohesive tracking network. Uniform and acceptable data standards, easily understood case definitions, and improved communication between health and environmental agencies are just a few of the challenges that must be addressed for this network to be effective. The nascent EPHT program is attempting to respond to these challenges by drawing on a wide range of expertise from federal agencies, state health and environmental agencies, nongovernmental organizations, and the program’s academic Centers of Excellence. In this mini-monograph, we present innovative strategies and methods that are being applied to the broad scope of important and complex environmental public health problems by developing EPHT programs. The data resulting from this program can be used to identify areas and populations most likely to be affected by environmental contamination and to provide important information on the health and environmental status of communities. EPHT will develop valuable data on possible associations between the environment and the risk of noninfectious health effects. These data can be used to reduce the burden of adverse health effects on the American public.
PMCID: PMC1247569  PMID: 15471734
environmental monitoring; environmental public health surveillance; information system integration; tracking
9.  Development and Status of the National Oral Health Surveillance System 
Preventing Chronic Disease  2009;6(2):A66.
During the last 2 decades of the 20th century, few national, state, or local oral health programs were able to conduct public health surveillance in a timely fashion. Under the leadership of the Association of State and Territorial Dental Directors and with substantial support from the Division of Oral Health at the Centers for Disease Control and Prevention, the National Oral Health Surveillance System was established as a first step in helping oral health programs routinely document population needs and program impact with standard, feasible methods. In 1999, the Council of State and Territorial Epidemiologists approved 7 oral health indicators for public health surveillance: 3 for adults (most recent dental visit, most recent dental cleaning, total tooth loss) using data from the Behavioral Risk Factor Surveillance System; 3 for third-grade students (presence of treated or untreated dental caries, untreated tooth decay, dental sealants) collected by states using a standard screening protocol; and the percentage of the population served by public water systems that receives optimally fluoridated water, tracked through the Water Fluoridation Reporting System. The Web site that describes the National Oral Health Surveillance System ( and provides access to current indicators was launched in 2001 with adult and water fluoridation data for all states; child indicators were added later. Data are now available electronically for 35 to 51 states (including the District of Columbia), depending on the indicator, indicating progress toward state-specific monitoring of these oral health indicators.
PMCID: PMC2687872  PMID: 19289009
10.  Electronic immunization data collection systems: application of an evaluation framework 
Evaluating the features and performance of health information systems can serve to strengthen the systems themselves as well as to guide other organizations in the process of designing and implementing surveillance tools. We adapted an evaluation framework in order to assess electronic immunization data collection systems, and applied it in two Ontario public health units.
The Centers for Disease Control and Prevention’s Guidelines for Evaluating Public Health Surveillance Systems are broad in nature and serve as an organizational tool to guide the development of comprehensive evaluation materials. Based on these Guidelines, and informed by other evaluation resources and input from stakeholders in the public health community, we applied an evaluation framework to two examples of immunization data collection and examined several system attributes: simplicity, flexibility, data quality, timeliness, and acceptability. Data collection approaches included key informant interviews, logic and completeness assessments, client surveys, and on-site observations.
Both evaluated systems allow high-quality immunization data to be collected, analyzed, and applied in a rapid fashion. However, neither system is currently able to link to other providers’ immunization data or provincial data sources, limiting the comprehensiveness of coverage assessments. We recommended that both organizations explore possibilities for external data linkage and collaborate with other jurisdictions to promote a provincial immunization repository or data sharing platform.
Electronic systems such as the ones described in this paper allow immunization data to be collected, analyzed, and applied in a rapid fashion, and represent the infostructure required to establish a population-based immunization registry, critical for comprehensively assessing vaccine coverage.
PMCID: PMC3898919  PMID: 24423014
Immunization; Information systems; Data collection; Program evaluation
11.  Designing a Natural Experiment to Evaluate a National Health Care–Community Partnership to Prevent Type 2 Diabetes 
To address the growing incidence of type 2 diabetes in the United States, UnitedHealth Group, the YMCA of the USA, and the Centers for Disease Control and Prevention have partnered to bring a group-based adaptation of the Diabetes Prevention Program lifestyle intervention to a national scale. Researchers at Northwestern and Indiana universities are collaborating with these partners to design a robust evaluation of the reach, effectiveness, and costs of this natural experiment. We will employ a quasi-experimental, cluster-randomized study design and combine administrative, clinical, and programmatic data from existing sources to derive reliable, timely, and policy-relevant estimates of the program’s impact and potential for sustainability. In this context, evaluation results will provide information about the unique role of a health care–community partnership to prevent type 2 diabetes.
PMCID: PMC3562224  PMID: 23369765
12.  Enhanced Surveillance during the Democratic National Convention, Charlotte, NC 
To describe how the existing state syndromic surveillance system (NC DETECT) was enhanced to facilitate surveillance conducted at the Democratic National Convention in Charlotte, North Carolina from August 31, 2012 to September 10, 2012.
North Carolina hosted the 2012 Democratic National Convention, September 3–6, 2012. The NC Epidemiology and Surveillance Team was created to facilitate enhanced surveillance for injuries and illnesses, early detection of outbreaks during the DNC, assist local public health with epidemiologic investigations and response, and produce daily surveillance reports for internal and external stakeholders. Surveillane data were collected from several data sources, including North Carolina Electronic Disease Surveillance System (NC EDSS), triage stations, and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT).
NC DETECT was created by the North Carolina Division of Public Health (NC DPH) in 2004 in collaboration with the Carolina Center for Health Informatics (CCHI) in the UNC Department of Emergency Medicine to address the need for early event detection and timely public health surveillance in North Carolina using a variety of secondary data sources. The data from emergency departments, the Carolinas Poison Center, the Pre-hospital Medical Information System (PreMIS) and selected Urgent Care Centers were available for monitoring by authorized users during the DNC.
Within NC DETECT, new dashboards were created that allowed epidemiologists to monitor ED visits and calls to the poison center in the Charlotte area, the greater Cities Readiness Initiative region and the entire state for infectious disease signs and symptoms, injuries and any mention of bioterrorism agents. The dashboards also included a section to view user comments on the information presented in NC DETECT. Data processing changes were also made to improve the timeliness of the EMS data received from PreMIS.
The DNC dashboards added to NC DETECT streamlined the workflow by placing all syndromes and annotations of interest in one place, with the date ranges and locations already pre-selected. Graphs in the dashboards could be easily copied and pasted into situation reports. The prompt development of these user-friendly tools provided effective surveillance for this mass gathering and ensured timely control measures, if necessary.
Syndromic surveillance systems can be enhanced to provide detailed, specific surveillance during mass gathering events. Elements that facilitate this enhancement include strong communication between skilled users and the informatics team, in order to minimize the burden placed on the surveillance team system users, data sources and system developers during the event. The visualizations developed as part of these new dashboards will be leveraged to provide additional tools to other NC DETECT user groups, including hospital-based public health epidemiologists and local health department users.
PMCID: PMC3692843
dashboards; enhanced surveillance; Democratic National Convention
13.  Charting a Path to Location Intelligence for STD Control 
Public Health Reports  2009;124(Suppl 2):49-57.
This article describes the New York State Department of Health's GeoDatabase project, which developed new methods and techniques for designing and building a geocoding and mapping data repository for sexually transmitted disease (STD) control. The GeoDatabase development was supported through the Centers for Disease Control and Prevention's Outcome Assessment through Systems of Integrated Surveillance workgroup. The design and operation of the GeoDatabase relied upon commercial-off-the-shelf tools that other public health programs may also use for disease-control systems. This article provides a blueprint of the structure and software used to build the GeoDatabase and integrate location data from multiple data sources into the everyday activities of STD control programs.
PMCID: PMC2775400
14.  Evaluation of Clinical and Administrative Data to Augment Public Health Surveillance 
To assess the utility of inpatient and ambulatory clinical data compiled by public and commercial sources to enhance the Centers for Disease Control and Prevention’s surveillance activities.
Medical claims and EHR data sources offer the potential to ascertain disease and health risk behavior prevalence and incidence, evaluate the use of clinical services, and monitor changes related to public health interventions. Passage of the HITECH Act of 2009 supports the availability of standardized EHR data for use by public health officials to obtain actionable information. While full adoption of EHRs is still years away, there are presently publicly- and commercially-available EHR and medical claims data sets that could enhance public health surveillance at a national, regional and state level. The purposes of this evaluation were to i.) demonstrate the feasibility of gaining access to such data, ii.) evaluate their ability to augment current surveillance activities by developing measures for twenty separate healthcare indicators (e.g., HIV screening), iii.) evaluate each data source across a set of criteria needed for an effective surveillance system, and iv.) assess the ability of the data sources to evaluate changes in healthcare utilization and preventive services that may be a result of the 2009 Health Reform legislation.
Ten separate data sources were selected for inclusion in the study based on a number of criteria, including availability, representativeness, population, data structure and content, cost, and longitudinality. In collaboration with staff from seven Divisions across the CDC, detailed specifications were developed for twenty separate indicators of healthcare utilization or preventive services using best practices in healthcare quality measurement. Specifications were developed separately for EHR and medical claims data due to their differing structure, content and use of medical code sets and terminologies. Specifications for EHR data sources relied on the National Quality Forum (NQF) Meaningful Use (MUse) clinical quality measure specifications. The use of NQF MUse specification guidelines allowed us to gauge the current ability of each data source to measure healthcare utilization and preventive services as recommended by NQF, the national leader in healthcare measurement. Each of the data sources was also evaluated across established public health surveillance criteria, including data quality, representativeness, and flexibility, among others. Data analysis was performed using SAS 9.3 (SAS Institute, Cary, NC).
All twenty of the healthcare indicators were developed for at least one data source; however, many of the indicator specifications had to be modified due to the low frequency of certain code sets (e.g., CPT-4 II, LOINC). The observed strengths of medical claims data were the relatively low cost, ability to track patients longitudinally, and the standardized representation of procedures and diagnoses through use of medical codes, such as ICD-9-CM, CPT-4 and HCPCS. The observed strengths of EHR data sources were the availability of information related to health behavior (e.g., current smoker), health assessment (e.g., BMI), prognostic indicators (e.g., vital signs, laboratory result), diagnostic testing, and functional status. While EHR data also capture diagnoses using ICD-9-CM, procedures such as medical and laboratory procedures remain documented through use of free text or semi-structured text fields, making it difficult to process.
Currently available healthcare data can improve the timeliness of health outcome monitoring and add complementary information on healthcare utilization to improve our interpretation of traditional public health surveillance data. Medical claims data support measurement of health outcomes and healthcare services provided to patient populations; however, without clinical encounter information, they cannot develop measures estimating the impact of services received on quality of care. EHR data have richer clinical information; however, the continued use of non-standards-based medical codes and free and semi-structured text fields make it difficult to analyze data at scale. Meaningful Use and other HITECH initiatives are changing this by incentivizing the standardization and aggregation of electronic healthcare data. In time, these data may yield timely, accurate and actionable information for public health surveillance.
PMCID: PMC3692874
Surveillance; Evaluation; Healthcare; Electronic Health Record
15.  Construction of a Multisite DataLink Using Electronic Health Records for the Identification, Surveillance, Prevention, and Management of Diabetes Mellitus: The SUPREME-DM Project 
Electronic health record (EHR) data enhance opportunities for conducting surveillance of diabetes. The objective of this study was to identify the number of people with diabetes from a diabetes DataLink developed as part of the SUPREME-DM (SUrveillance, PREvention, and ManagEment of Diabetes Mellitus) project, a consortium of 11 integrated health systems that use comprehensive EHR data for research.
We identified all members of 11 health care systems who had any enrollment from January 2005 through December 2009. For these members, we searched inpatient and outpatient diagnosis codes, laboratory test results, and pharmaceutical dispensings from January 2000 through December 2009 to create indicator variables that could potentially identify a person with diabetes. Using this information, we estimated the number of people with diabetes and among them, the number of incident cases, defined as indication of diabetes after at least 2 years of continuous health system enrollment.
The 11 health systems contributed 15,765,529 unique members, of whom 1,085,947 (6.9%) met 1 or more study criteria for diabetes. The nonstandardized proportion meeting study criteria for diabetes ranged from 4.2% to 12.4% across sites. Most members with diabetes (88%) met multiple criteria. Of the members with diabetes, 428,349 (39.4%) were incident cases.
The SUPREME-DM DataLink is a unique resource that provides an opportunity to conduct comparative effectiveness research, epidemiologic surveillance including longitudinal analyses, and population-based care management studies of people with diabetes. It also provides a useful data source for pragmatic clinical trials of prevention or treatment interventions.
PMCID: PMC3457753  PMID: 22677160
16.  Influence of Family History of Diabetes on Health Care Provider Practice and Patient Behavior Among Nondiabetic Oregonians 
Preventing Chronic Disease  2008;6(1):A27.
People with a family history of diabetes are at increased risk of developing diabetes; however, the effect of family history of diabetes on health care provider practice and patient behavior has not been well defined.
We analyzed data from the 2005 Oregon Behavioral Risk Factor Surveillance System, a state-based, random-digit–dialed telephone survey, to evaluate, among people with diabetes, associations between family history of diabetes and 1) patients' reports of health care provider practices, 2) patients' perceived risk of developing diabetes, and 3) patients' behaviors associated with an increased risk of developing diabetes.
Compared with respondents at average risk, respondents with a positive family history (strong or moderate familial risk for diabetes) were more likely to report that their health care provider collects family history information about diabetes, discusses the risk of developing diabetes or other chronic conditions, and makes recommendations to change their diet or exercise behaviors to reduce the chance of developing diabetes. Respondents with a strong family history of diabetes were 5 times more likely to be very or somewhat worried about developing diabetes than were people at average risk (odds ratio [OR], 5.0; 95% confidence interval [CI], 4.0-6.2). Compared with respondents at average risk, respondents with a strong family history were more likely to report making changes in diet and exercise (OR, 1.7; 95% CI, 1.4-2.1).
Integrating family history of diabetes into clinical practice offers opportunities to improve the effectiveness of diabetes detection and to promote interventions aimed at preventing or delaying the development of diabetes in people at high risk.
PMCID: PMC2644593  PMID: 19080033
17.  The State Public Health Laboratory System 
Public Health Reports  2010;125(Suppl 2):4-17.
This article describes the development since 2000 of the State Public Health Laboratory System in the United States. These state systems collectively are related to several other recent public health laboratory (PHL) initiatives. The first is the Core Functions and Capabilities of State Public Health Laboratories, a white paper that defined the basic responsibilities of the state PHL. Another is the Centers for Disease Control and Prevention National Laboratory System (NLS) initiative, the goal of which is to promote public-private collaboration to assure quality laboratory services and public health surveillance.
To enhance the realization of the NLS, the Association of Public Health Laboratories (APHL) launched in 2004 a State Public Health Laboratory System Improvement Program. In the same year, APHL developed a Comprehensive Laboratory Services Survey, a tool to measure improvement through the decade to assure that essential PHL services are provided.
PMCID: PMC2846798  PMID: 20521374
18.  Towards Web-based representation and processing of health information 
There is great concern within health surveillance, on how to grapple with environmental degradation, rapid urbanization, population mobility and growth. The Internet has emerged as an efficient way to share health information, enabling users to access and understand data at their fingertips. Increasingly complex problems in the health field require increasingly sophisticated computer software, distributed computing power, and standardized data sharing. To address this need, Web-based mapping is now emerging as an important tool to enable health practitioners, policy makers, and the public to understand spatial health risks, population health trends and vulnerabilities. Today several web-based health applications generate dynamic maps; however, for people to fully interpret the maps they need data source description and the method used in the data analysis or statistical modeling. For the representation of health information through Web-mapping applications, there still lacks a standard format to accommodate all fixed (such as location) and variable (such as age, gender, health outcome, etc) indicators in the representation of health information. Furthermore, net-centric computing has not been adequately applied to support flexible health data processing and mapping online.
The authors of this study designed a HEalth Representation XML (HERXML) schema that consists of the semantic (e.g., health activity description, the data sources description, the statistical methodology used for analysis), geometric, and cartographical representations of health data. A case study has been carried on the development of web application and services within the Canadian Geospatial Data Infrastructure (CGDI) framework for community health programs of the New Brunswick Lung Association. This study facilitated the online processing, mapping and sharing of health information, with the use of HERXML and Open Geospatial Consortium (OGC) services. It brought a new solution in better health data representation and initial exploration of the Web-based processing of health information.
The designed HERXML has been proven to be an appropriate solution in supporting the Web representation of health information. It can be used by health practitioners, policy makers, and the public in disease etiology, health planning, health resource management, health promotion and health education. The utilization of Web-based processing services in this study provides a flexible way for users to select and use certain processing functions for health data processing and mapping via the Web. This research provides easy access to geospatial and health data in understanding the trends of diseases, and promotes the growth and enrichment of the CGDI in the public health sector.
PMCID: PMC2651125  PMID: 19159445
19.  Can Internet Access Growth Help Reduce the Global Burden Of Noncommunicable Diseases? 
Noncommunicable diseases, such as cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes, are currently the leading causes of death in several regions of the world. The continuing fast increase in the global burden of noncommunicable diseases is accompanied by a speedy worldwide internet access growth. The worldwide number of internet users has doubled over the past five years. As the internet can make the access to information on a healthy lifestyle and disease prevention activities easier, internet access growth may help to promote good health. Against this background, I discuss the roles the internet and access to information can play in health promotion. I also present an open access web portal on local prevention and health promotion activities. It was initiated by two German states to link health information from disparate sources and to organize this information in a user-friendly way. The web portal focuses on reducing preventable lifestyle-related risk factors associated with noncommunicable diseases, including physical inactivity, unhealthy diet, tobacco use, and the harmful use of alcohol. This local initiative has the potential for scaling up and can serve as a blueprint for other areas that have or will acquire internet access.
PMCID: PMC3733764  PMID: 23923103
internet; health promotion; open access; prevention; scale up; web portal
20.  The Annual African American Conference on Diabetes: Evolving Program Evaluation With Evolving Program Implementation 
Preventing Chronic Disease  2005;3(1):A18.
According to 2003 Behavioral Risk Factor Surveillance System data, South Carolina has the fourth highest rate of overall diabetes among the 50 states (9.3%) but the second highest rate among African Americans (15.5%). Nationwide, African Americans are disproportionately affected by diabetes. In addition, 40% of the African American population in South Carolina lives in a rural area, and approximately 26% live at or below the poverty level. Lack of access to health care and diabetes education are additional barriers for people with diabetes and their families.
Since 1997, the South Carolina Diabetes Prevention and Control Program and the Diabetes Today Advisory Council have sponsored the African American Conference on Diabetes, which targets African Americans with diabetes, their families, and their caregivers. This article describes the evolution of the conference and its evaluation.
In 2002, we conducted focus groups with 20 African American conference attendees with diabetes to 1) assess the program's effects, 2) determine how to reach more individuals, and 3) improve programming. In 2004, we incorporated the preconference and postconference Diabetes Understanding Scale survey to assess the cognitive impact of the conference on participants.
Focus group results revealed that participants wanted to attend the conference because of the opportunity to increase their knowledge and change their behaviors through 1) education, 2) social support, 3) resources, and 4) logistics. Self-rated understanding increased significantly after the conference for each cognitive understanding item on the Diabetes Understanding Scale.
Focus group results suggested that participants who continue to attend the conference year after year may improve diabetes self-management skills. A quantitative evaluation showed that this 1-day diabetes education conference significantly increased short-term, self-rated cognitive understanding of diabetes behaviors.
PMCID: PMC1500944  PMID: 16356371
21.  A Type 2 Diabetes Prevention Website for African Americans, Caucasians, and Mexican Americans: Formative Evaluation 
JMIR Research Protocols  2013;2(2):e24.
The majority of Americans now access the Internet, thereby expanding prospects for Web-based health-related education and intervention. However, there remains a digital divide among those with lower income and education, and among Spanish-speaking populations in the United States. Additional concerns are the low eHealth literacy rate among these populations and their interest in Internet-delivered interventions with these components. Given these factors, combined with the prevalence of type 2 diabetes among low socioeconomic status and Spanish-speaking Americans, strides need to be taken to reach these populations with online tools for diabetes prevention and management that are at once accessible and efficacious.
Using a formative evaluation of an eHealth diabetes prevention and control website, we tested the extent to which African Americans, Caucasians, and Mexican Americans at risk for type 2 diabetes gained knowledge and intended to modify their dietary intake and physical activity subsequent to viewing the website. We also examined their general Internet use patterns related to type 2 diabetes.
A mixed methods approach was undertaken. The diabetes prevention and control website provided educational and behavioral change information in English and Spanish. For this study, eligible participants (1) completed a prequantitative survey, (2) interacted with the website, (3) completed a qualitative interview, and (4) completed a postquantitative survey.
After finding a significant differences in posttest diabetes knowledge scores (P<.001), a regression analysis controlling for pretest score, health literacy, ethnicity, Transtheoretical Model Stage for exercise and fruit and vegetable consumption, and Internet literacy was conducted. Internet literacy score (P=.04) and fruit and vegetable consumption stage (P<.001) were significantly associated with posttest scores indicating that those in precontemplation stage and with low Internet literacy scores were less likely to show improved diabetes knowledge scores. We found significant difference in posttest intention to eat a healthy diet each day in the next 2 months after controlling for pretest score, health literacy, ethnicity, Transtheoretical Model Stage for fruit and vegetable consumption and Internet literacy. Those in the Action stage of the Transtheoretical model for exercise were significantly less likely (P=.023) to improve the posttest score for intention to eat a healthy diet compared to those in the Preparation stage for exercise. We also found that health information is sought commonly across ethnic groups, but that diabetes-related information is less commonly sought even among those at risk. Other specific ethnic usage patterns were identified in the qualitative data including content sought on Web searches and technology used to access the Internet.
This study provides in-depth qualitative insight into the seeking, access, and use of Web-based health information across three ethnic groups in two languages. Additionally, it provides evidence from pre-post measures of exposure to Web-based health content and related changes in diabetes knowledge and intention to eat a healthy diet.
PMCID: PMC3713918  PMID: 23846668
diabetes; Internet; Mexican-Americans; African Americans; socioeconomic status; dietary intake; physical activity; health literacy; website
22.  HepSEQ: International Public Health Repository for Hepatitis B 
Nucleic Acids Research  2006;35(Database issue):D367-D370.
HepSEQ is a repository for an extensive library of public health and molecular data relating to hepatitis B virus (HBV) infection collected from international sources. It is hosted by the Centre for Infections, Health Protection Agency (HPA), England, United Kingdom. This repository has been developed as a web-enabled, quality-controlled database to act as a tool for surveillance, HBV case management and for research. The web front-end for the database system can be accessed from . The format of the database system allows for comprehensive molecular, clinical and epidemiological data to be deposited into a functional database, to search and manipulate the stored data and to extract and visualize the information on epidemiological, virological, clinical, nucleotide sequence and mutational aspects of HBV infection through web front-end. Specific tools, built into the database, can be utilized to analyse deposited data and provide information on HBV genotype, identify mutations with known clinical significance (e.g. vaccine escape, precore and antiviral-resistant mutations) and carry out sequence homology searches against other deposited strains. Further mechanisms are also in place to allow specific tailored searches of the database to be undertaken.
PMCID: PMC1716715  PMID: 17130143
23.  Measuring health-related quality of life for public health surveillance. 
Public Health Reports  1994;109(5):665-672.
In public health research and practice, quality of life is increasingly acknowledged as a valid and appropriate indicator of service need and intervention outcomes. Health-related quality of life measures, including objective and subjective assessments of health, are particularly useful for evaluating efforts in the prevention of disabling chronic diseases. Such data can inform health policy, planning, and practice. Mechanisms for routinely monitoring quality of life of populations at the State and local levels are currently lacking, however. This article discusses the rationale for and concepts measured by four quality of life questions developed for the 1993 Behavioral Risk Factor Surveillance System, a State-based telephone surveillance system. To encourage quality of life surveillance by States, the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion held two related workshops, one in December 1991 and the other in June 1992. The workshops convened experts in quality of life and functional status measurement and resulted in the formulation of items for the Behavioral Risk Factor Surveillance System on self-perceived health, recent physical and mental health, and recent limitation in usual activities. The criteria, including feasibility and generalizability, considered by the Centers for Disease Control and Prevention and the workshop participants in the selection and development of these items are discussed. A model that conceptualizes the relationship of quality of life domains measured by the four survey items is presented and validated with preliminary data from the 1993 Behavioral Risk Factor Surveillance System. Finally, how States can use these measures to track progress towards the Year 2000 goal of improving quality of life is discussed.
PMCID: PMC1403555  PMID: 7938388
24.  Integrating Research, Surveillance, and Practice in Environmental Public Health Tracking 
Environmental Health Perspectives  2006;114(7):980-984.
The Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services is working with selected state and local health departments, academic centers, and others to develop an environmental public health tracking initiative to improve geographic and temporal surveillance of environmental hazards, exposures, and related health outcomes. The objective is to support policy strategies and interventions for disease prevention by communities and environmental health agencies at the federal, state, and local levels. The first 3 years of the initiative focused on supporting states and cities in developing capacity, information technology infrastructure, and pilot projects to demonstrate electronic linkage of environmental hazard or exposure data and disease data. The next phase requires implementation across states. This transition could provide opportunities to further integrate research, surveillance, and practice through attention to four areas. The first is to develop a shared and transparent knowledge base that draws on environmental health research and substantiates decisions about what to track and the interpretation of results. The second is to identify and address information needs of policy and stakeholder audiences in environmental health. The third is to adopt mechanisms for coordination, decision making, and governance that can incorporate and support the major entities involved. The fourth is to promote disease prevention by systematically identifying and addressing population-level environmental determinants of health and disease.
PMCID: PMC1513336  PMID: 16835047
chronic disease; disease surveillance; environmental exposure; environmental health; environmental health indicators; environmental health policy; environmental monitoring; environmental public health tracking; population health; public health surveillance
25.  Lifestyle change in Kerala, India: needs assessment and planning for a community-based diabetes prevention trial 
BMC Public Health  2013;13:95.
Type 2 Diabetes Mellitus (T2DM) has become a major public health challenge in India. Factors relevant to the development and implementation of diabetes prevention programmes in resource-constrained countries, such as India, have been under-studied. The purpose of this study is to describe the findings from research aimed at informing the development and evaluation of a Diabetes Prevention Programme in Kerala, India (K-DPP).
Data were collected from three main sources: (1) a systematic review of key research literature; (2) a review of relevant policy documents; and (3) focus groups conducted among individuals with a high risk of progressing to diabetes. The key findings were then triangulated and synthesised.
Prevalence of risk factors for diabetes is very high and increasing in Kerala. This situation is largely attributable to rapid changes in the lifestyle of people living in this state of India. The findings from the systematic review and focus groups identified many environmental and personal determinants of these unhealthy lifestyle changes, including: less than ideal accessibility to and availability of health services; cultural values and norms; optimistic bias and other misconceptions related to risk; and low expectations regarding one’s ability to make lifestyle changes in order to influence health and disease outcomes. On the other hand, there are existing intervention trials conducted in India which suggests that risk reduction is possible. These programmes utilize multi-level strategies including mass media, as well as strategies to enhance community and individual empowerment. India’s national programme for the prevention and control of major non-communicable diseases (NCD) also provide a supportive environment for further community-based efforts to prevent diabetes.
These findings provide strong support for undertaking more research into the conduct of community-based diabetes prevention in the rural areas of Kerala. We aim to develop, implement and evaluate a group-based peer support programme that will address cultural and family determinants of lifestyle risks, including family decision-making regarding adoption of healthy dietary and physical activity patterns. Furthermore, we believe that this approach will be feasible, acceptable and effective in these communities; with the potential for scale-up in other parts of India.
PMCID: PMC3576354  PMID: 23375152
Diabetes mellitus; Real world intervention; Diabetes prevention; Pre-diabetes

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